Lenvatinib, toripalimab plus hepatic arterial infusion chemotherapy in patients with high-risk advanced hepatocellular carcinoma: A biomolecular exploratory, phase II trial

RALOX-HAIC (raltitrexed + oxaliplatin) combined with lenvatinib improves survival and safety in elderly patients with unresectable hepatocellular carcinoma

OBJECTIVE

To explore the efficacy and safety of RALOX-HAIC (raltitrexed plus oxaliplatin) combined with lenvatinib in the treatment of elderly patients with unresectable hepatocellular carcinoma (uHCC), aiming to provide a safer and more effective therapeutic strategy for this patient population.

MATERIALS AND METHODS

A retrospective analysis was conducted on the clinical data of 82 elderly patients with uHCC who received treatment in the Department of Interventional Radiology at Wuhan Union Hospital from January 2019 to December 2022. Patients were divided into two groups based on their treatment strategy: HAIC + Lenvatinib group (N = 39) and TACE group (N = 43). The primary endpoints were the objective response rate (ORR), disease control rate (DCR), overall survival (OS), and progression-free survival (PFS) in the two groups. The secondary endpoint was the incidence of treatment-related adverse events in both groups.

RESULTS

The ORR and DCR after treatment were higher in the HAIC + Lenvatinib group compared to the TACE group (61.5% vs. 37.2%, 82.1% vs. 58.1%, P < 0.05). The HAIC + Lenvatinib group had a longer median progression-free survival (mPFS,9.2 months vs. 4.6 months, P < 0.001) and ​median overall survival(mOS, 18.1 months vs. 10.6 months, P < 0.001) compared to the TACE group. The incidence of abdominal pain and fever was significantly higher in the TACE group than in the HAIC + Lenvatinib group (including all grades and grades 3/4, P < 0.05). The incidence of hand-foot syndrome (all grades) was higher in the HAIC + Lenvatinib group compared to the TACE group (15.4% vs. 0.0%, P = 0.009), but there was no significant difference in the incidence of grade 3/4 hand-foot syndrome between the two groups (2.6% vs. 0.0%, P = 0.476).

CONCLUSION

This study demonstrates that RALOX-HAIC combined with lenvatinib provides superior survival outcomes and tolerability compared to TACE alone ​in elderly patients (≥ 70 years) with unresectable HCC. This combination therapy may be a feasible and safe option for improving the prognosis of elderly patients with uHCC.

Radiotherapy, tyrosine kinase inhibitors, immune checkpoint inhibitors combined with hepatic arterial infusion chemotherapy of RALOX versus FOLFOX for hepatocellular carcinoma with portal vein tumor thrombus: a propensity score-matching cohort study

BACKGROUND

This retrospective study aimed to evaluate the safety and effectiveness of hepatic arterial infusion chemotherapy with raltitrexed and oxaliplatin (RALOX-HAIC) combined with radiotherapy, tyrosine kinase inhibitors, and immune checkpoint inhibitors in patients with hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT).

METHODS

A propensity score-matching (PSM) cohort study was conducted. The tumor response, treatment-related adverse events, survival outcomes were compared. Univariate and multivariate analyses were conducted to explore the risk factors of overall survival (OS).

RESULTS

Twenty-one pairs of patients were evaluated after PSM. No statistical differences were found in the tumor response, objective response rate, disease control rate, PVTT response, surgical resection rate, metastasis, and mortality between the two groups before and after PSM. Compared with the FOLFOX-HAIC group, the incidences of abdominal pain and fever was lower in the RALOX-HAIC group (P = 0.028, P = 0.029). These differences still had statistical significance after PSM (P = 0.013, P = 0.014). No statistical differences were found in OS and progression-free survival (PFS) between the two groups before and after PSM (Before [OS: hazard ratio(HR) = 1.138; 95%CI 0.569-2.276, P = 0.715; PFS: HR = 0.549; 95%CI 0.195-1.548, P = 0.257; After [OS: HR = 0.998; 95%CI 0.438-2.274, P = 0.995; PFS: HR = 0.792; 95%CI 0.359-1.748, P = 0.564]). The prealbumin < 170 mg/L before therapy was an independent risk factor for OS (HR = 2.234; 95%CI 1.051-4.751; P = 0.037).

CONCLUSIONS

The RALOX-HAIC combined radiotherapy, TKI, and ICI may provide similar survival advantages with fewer treatment-related abdominal pain and fever compared to FOLFOX-HAIC for HCC patients with PVTT. The prealbumin < 170 mg/L before therapy is an independent risk factor for OS.

Hepatic artery infusion of FOLFOX chemotherapy plus camrelizumab combined with sorafenib for advanced hepatocellular carcinoma in Barcelona Clinic Liver Cancer stage C (Double-IA-001): a phase II trial

BACKGROUND

Hepatic arterial infusion chemotherapy (HAIC) with a combination of oxaliplatin, fluorouracil, and leucovorin (FOLFOX) has shown excellent local control for patients with Barcelona Clinic Liver Cancer (BCLC) stage C hepatocellular carcinoma (HCC). In China, both camrelizumab (a programmed cell death-1 [PD-1] inhibitor) and sorafenib have been approved for the first-line treatment of advanced HCC. This study aimed to investigate the efficacy and safety of hepatic artery infusion of FOLFOX chemotherapy plus camrelizumab combined with sorafenib in BCLC stage C advanced HCC.

METHODS

This was a single-arm phase II trial (ChiCTR2100041874) with a Simon's two-stage design. Eligible patients were given a maximum of 6 cycles of hepatic artery infusion with FOLFOX chemotherapy plus camrelizumab (200 mg once every 3 weeks). Sorafenib (400 mg orally twice daily) was given since day 3 after the completion of the first cycle of hepatic artery infusion until disease progression, intolerable toxicity, or conversion to surgical resection. The primary endpoint was objective response rate (ORR) based on the modified Response Evaluation Criteria In Solid Tumors (mRECIST).

RESULTS

Between January 4, 2021, and December 11, 2023, 25 patients were enrolled. Eleven patients had partial response, with an ORR of 44.0% (95% CI, 24.6-63.5%). The primary endpoint was not met, and the study failed to enter the second stage. Median progression-free survival was 4.87 months (95% CI, 2.07-7.66), with a 12-month rate of 23.2%. Median overall survival was 8.87 months (95% CI, 8.17-9.57), with 12- and 24-month rates of 40.3% and 26.9%, respectively. Two (8.0%) patients received curative resection after the study treatment. Grade ≥ 3 treatment-related adverse events occurred in 19 (76.0%) patients, with the most common being decreased lymphocyte count (13 [52.0%]), increased aspartate aminotransferase (11 [44.0%]), and increased alanine aminotransferase (seven [28.0%]).

CONCLUSIONS

Hepatic artery infusion of FOLFOX chemotherapy plus camrelizumab combined with oral sorafenib shows manageable safety profile but modest antitumor activity in patients with BCLC stage C advanced HCC.

A Contrast-Enhanced Ultrasound Cine-Based Deep Learning Model for Predicting the Response of Advanced Hepatocellular Carcinoma to Hepatic Arterial Infusion Chemotherapy Combined With Systemic Therapies

Recently, a hepatic arterial infusion chemotherapy (HAIC)-associated combination therapeutic regimen, comprising HAIC and systemic therapies (molecular targeted therapy plus immunotherapy), referred to as HAIC combination therapy, has demonstrated promising anticancer effects. Identifying individuals who may potentially benefit from HAIC combination therapy could contribute to improved treatment decision-making for patients with advanced hepatocellular carcinoma (HCC). This dual-center study was a retrospective analysis of prospectively collected data with advanced HCC patients who underwent HAIC combination therapy and pretreatment contrast-enhanced ultrasound (CEUS) evaluations from March 2019 to March 2023. Two deep learning models, AE-3DNet and 3DNet, along with a time-intensity curve-based model, were developed for predicting therapeutic responses from pretreatment CEUS cine images. Diagnostic metrics, including the area under the receiver-operating-characteristic curve (AUC), were calculated to compare the performance of the models. Survival analysis was used to assess the relationship between predicted responses and prognostic outcomes. The model of AE-3DNet was constructed on the top of 3DNet, with innovative incorporation of spatiotemporal attention modules to enhance the capacity for dynamic feature extraction. 326 patients were included, 243 of whom formed the internal validation cohort, which was utilized for model development and fivefold cross-validation, while the rest formed the external validation cohort. Objective response (OR) or non-objective response (non-OR) were observed in 63% (206/326) and 37% (120/326) of the participants, respectively. Among the three efficacy prediction models assessed, AE-3DNet performed superiorly with AUC values of 0.84 and 0.85 in the internal and external validation cohorts, respectively. AE-3DNet's predicted response survival curves closely resembled actual clinical outcomes. The deep learning model of AE-3DNet developed based on pretreatment CEUS cine performed satisfactorily in predicting the responses of advanced HCC to HAIC combination therapy, which may serve as a promising tool for guiding combined therapy and individualized treatment strategies. Trial Registration: NCT02973685.

Predictive factors and prognostic models for Hepatic arterial infusion chemotherapy in Hepatocellular carcinoma: a comprehensive review

Hepatocellular carcinoma (HCC) is a prevalent and lethal cancer, often diagnosed at advanced stages where traditional treatments such as surgical resection, liver transplantation, and locoregional therapies provide limited benefits. Hepatic arterial infusion chemotherapy (HAIC) has emerged as a promising treatment modality for advanced HCC, enhancing anti-tumor efficacy through targeted drug delivery while minimizing systemic side effects. However, the heterogeneous nature of HCC leads to variable responses to HAIC, highlighting the necessity for reliable predictive indicators to tailor personalized treatment strategies. This review explores the factors influencing HAIC success, including patient demographics, tumor characteristics, biomarkers, genomic profiles, and advanced imaging techniques such as radiomics and deep learning models. Additionally, the synergistic potential of HAIC combined with immunotherapy and molecular targeted therapies is examined, demonstrating improved survival outcomes. Prognostic scoring systems and nomograms that integrate clinical, molecular, and imaging data are discussed as superior tools for individualized prognostication compared to traditional staging systems. Understanding these predictors is essential for optimizing HAIC efficacy and enhancing survival and quality of life for patients with advanced HCC. Future research directions include large-scale prospective studies, integration of multi-omics data, and advancements in artificial intelligence to refine predictive models and further personalize treatment approaches.

Targeting Metabolism: Innovative Therapies for MASLD Unveiled

The recent introduction of the term metabolic-dysfunction-associated steatotic liver disease (MASLD) has highlighted the critical role of metabolism in the disease's pathophysiology. This innovative nomenclature signifies a shift from the previous designation of non-alcoholic fatty liver disease (NAFLD), emphasizing the condition's progressive nature. Simultaneously, MASLD has become one of the most prevalent liver diseases worldwide, highlighting the urgent need for research to elucidate its etiology and develop effective treatment strategies. This review examines and delineates the revised definition of MASLD, exploring its epidemiology and the pathological changes occurring at various stages of the disease. Additionally, it identifies metabolically relevant targets within MASLD and provides a summary of the latest metabolically targeted drugs under development, including those in clinical and some preclinical stages. The review finishes with a look ahead to the future of targeted therapy for MASLD, with the goal of summarizing and providing fresh ideas and insights.

The safety and efficacy of tyrosine kinase inhibitors and programmed cell death protein- 1 inhibitors combined with HAIC/TACE in the treatment of recurrent unresectable hepatocellular carcinoma

BACKGROUND AND AIMS

Hepatocellular carcinoma (HCC) frequently recurs after surgical treatment, necessitating effective postoperative recurrence management for improved long-term patient outcomes. Currently, no standardized treatment approach exists for recurrent unresectable HCC. This study aims to investigate the safety and efficacy of combining tyrosine kinase inhibitors (TKIs) and programmed cell death protein-1 (PD-1) inhibitors with hepatic arterial infusion chemotherapy (HAIC) or transarterial chemoembolization (TACE) in the treatment of recurrent unresectable HCC.

METHODS

A retrospective analysis was conducted on clinical data from 83 patients diagnosed with unresectable recurrent HCC. Patients were categorized into three groups based on their treatment regimens: HAIC combined with TKIs and PD-1 inhibitors (HTP), TACE combined with TKIs and PD-1 inhibitors (TTP), and TACE alone. Treatment efficacy and safety were compared among these groups, and potential risk factors were identified.

RESULTS

The median progression-free survival (PFS) for patients in the HTP group, TTP group, and TACE alone group was found to be 13.7, 9.2, and 2.5 months (p = 0.001, p = 0.002). According to the mRECIST criteria, the disease control rates (DCR) in the HTP, TTP and TACE groups was 89.7%, 75.0%, 50.0% (p = 0.002); objective response rates (ORR) was 44.8%, 35%, 14.7% (p = 0.037); and complete response (CR) was 17.2%, 0, 0 (p = 0.005). No serious adverse reactions were observed in the HTP and TTP groups.

CONCLUSION

The HTP and TTP groups were safe and effective compared to TACE alone for the treatment of recurrent unresectable hepatocellular carcinoma, and the HTP group demonstrated a superior CR.

Efficacy and safety of TACE combined with TKIs and PD-1 inhibitors in HCC patients with prior TIPS

Purpose

To compare the efficacy and safety of TACE combined with TKIs and PD-1 inhibitors between HCC patients with and without prior TIPS.

Methods

This retrospective propensity score matching (PSM) study included advanced HCC patients treated with prior TIPS followed by TKIs, PD-1 inhibitors, and TACE between January 2021 and January 2023. Patients were matched with a control group of HCC patients who had not undergone TIPS (non-TIPS). Outcome measures included objective response rate (ORR) using modified RECIST (mRECIST v1.1), disease control rate (DCR), progression-free survival (PFS), overall survival (OS), and safety assessed by CTCAE v5.0.

Results

A total of 172 patients were included before PSM. After PSM, 42 patients with prior TIPS were matched with 71 non-TIPS patients. ORR was 31.0% in the TIPS group and 57.7% in the non-TIPS group (p = 0.007), Both PFS and OS were longer in the non-TIPS group, with a median PFS of 7.9 months for TIPS patients versus 12.3 months for non-TIPS patients (hazard ratio [HR] = 2.253, p < 0.001), and a median OS of 13.5 months versus 21.1 months, respectively (HR = 2.282, p = 0.002). Treatment-related adverse events showed no significant differences between the two groups.

Conclusion

TACE combined with TKIs and PD-1 inhibitors showed lower efficacy in HCC patients with prior TIPS, but it remains a viable option, providing a favorable safety profile and effective disease control.

Prognostic nutritional index predicts survival in intermediate and advanced hepatocellular carcinoma treated with hepatic arterial infusion chemotherapy combined with PD-(L)1 inhibitors and molecular targeted therapies

BACKGROUND

This study aimed to evaluate the predictive efficacy of the prognostic nutritional index (PNI) in patients with intermediate and advanced hepatocellular carcinoma (HCC) treated with a regimen consisting of hepatic arterial infusion chemotherapy (HAIC), PD-(L)1 inhibitors, and molecular targeted therapies (MTTs).

METHODS

A retrospective analysis was performed on the data of 88 HCC patients received triple therapy between January 2020 and August 2022 at three medical centers. Univariate and multivariable analyses were conducted to assess the relationship between PNI and survival outcomes.

RESULTS

The median follow-up was 11.0 months (IQR: 8.0-17.0). The PNI cut-off value of 38.6 was determined using receiver operating characteristics (ROC) analysis. The median overall survival (OS) durations were 29.0 and 8.0 months in the high-PNI (≥ 38.6) and low-PNI (≤ 38.6) groups, respectively (HR = 0.306, 95% CI, 0.170-0.552, P < 0.001), and the median progression-free survival (PFS) durations were16.0 and 6.0 months, respectively (HR = 0.521, 95% CI, 0.303-0.896, P = 0.014). A higher complete response rate was observed in the high-PNI group (17.5% vs. 3.2%, P = 0.033). The univariate and multivariable analyses revealed that a PNI of ≥ 38.6 had an independent influence on both median OS (HR = 0.296; 95% CI, 0.159-0.551, P < 0.001) and median PFS (HR = 0.560; 95% CI, 0.318-0.987, P = 0.045).

CONCLUSION

The PNI is an objective and convenient tool that can potentially predict the prognosis of patients treated with HAIC-based triple therapy.

Combination locoregional and systemic therapies in hepatocellular carcinoma

Locoregional therapies play a fundamental role in the treatment of patients with early and intermediate and locally advanced hepatocellular carcinomas. With encouraging recent advances in immunotherapy-based systemic therapies, locoregional therapies are being both promoted and challenged by new systemic therapy options. Combined locoregional and systemic therapies might enhance treatment outcomes compared with either option alone. This Series paper summarises the existing data on locoregional and systemic therapies for hepatocellular carcinoma, and discusses evidence from studies investigating their combination with a focus on their synergistic efficacy and safety.

Hepatic arterial infusion chemotherapy combined with lenvatinib and immune checkpoint inhibitor versus lenvatinib for advanced hepatocellular carcinoma: a multicenter study with propensity score and coarsened exact matching

PURPOSE

Hepatic arterial infusion chemotherapy (HAIC) combined with lenvatinib (Len) and immune checkpoint inhibitor (ICI) in treating advanced hepatocellular carcinoma (HCC) still needs further confirmation. We aimed to evaluate the efficacy of HAIC combined with Len and ICI (HAIC + Len + ICI) versus Len alone in advanced HCC.

METHODS

A total of 290 patients in Len group and 349 patients in HAIC + Len + ICI group were analysed. Propensity score matching (PSM), inverse probability treatment weighting (IPTW), and coarsened exact matching (CEM) analyses were used to balance the bias between two groups. Mediation analysis of treatment type in survival was performed for analysis.

RESULTS

The median progression-free survival (PFS) was 5.9 ± 0.2 months in Len group and 9.2 ± 0.5 months in HAIC + Len + ICI group. The HAIC + Len + ICI group demonstrated significantly better PFS than the Len group across the entire cohort (hazard ratio [HR], 0.50; 95% CI 0.43-0.60; P < 0.001). This advantage in PFS was sustained in the PSM, IPTW, and CEM cohorts. HAIC + Len + ICI group also showed better overall survival (OS) than the Len group (HR, 0.38; 95% CI 0.31-0.46; P < 0.001). The OS was also superior in the PSM, IPTW, and CEM cohorts. The objective response rate (ORR) in HAIC + Len + ICI group was twice as high as that in Len group. Further mediation analysis showed tumor response at 3 and 6 months had different mediation effect on survival.

CONCLUSIONS

HAIC combined with Len and ICI showed improved better OS and PFS than Len alone. This triple therapy could be considered as a first-line treatment for advanced HCC.

Neoadjuvant therapy for hepatocellular carcinoma-priming precision innovations to transform HCC treatment

Hepatocellular carcinoma (HCC) is increasing in prevalence globally, and cure remains limited with non-operative treatment. Surgical intervention, through resection or transplantation, offers a potential for cure for select patients. However, many patients present with advanced or unresectable disease, and recurrence rates remain high. Recent advances in systemic therapies, particularly immune checkpoint inhibitors, have demonstrated promise in treating unresectable HCC and as adjuvant therapy. Evidence from adjuvant trials highlights the synergistic potential of combined liver-directed and systemic therapies. These findings have ignited growing interest in neoadjuvant therapy across various scenarios: (1) as a bridging strategy while awaiting transplantation, (2) for downstaging disease to enable transplantation, (3) for converting unresectable disease to a resectable state, or (4) as neoadjuvant treatment in operable cases. Early-stage trials of neoadjuvant therapy in resectable HCC have reported promising outcomes. To realize the potential of neoadjuvant treatment for HCC, thoughtfully designed, adequately powered, multi-center clinical trials are essential.

Adverse events associated with hepatic arterial infusion chemotherapy and its combination therapies in hepatocellular carcinoma: a systematic review

Background

Hepatic arterial infusion chemotherapy (HAIC) has emerged as a promising treatment for unresectable hepatocellular carcinoma (HCC). However, the safety profiles of HAIC and its various combination therapies remain to be systematically evaluated.

Methods

We systematically searched PubMed, Embase, Cochrane Library, and Web of Science databases from inception to November 2024. Studies reporting adverse events (AEs) of HAIC monotherapy or combination therapies in HCC were included. The severity and frequency of AEs were analyzed according to different treatment protocols.

Results

A total of 58 studies (11 prospective, 47 retrospective) were included. HAIC monotherapy demonstrated relatively mild toxicity, primarily affecting hepatobiliary (transaminase elevation 53.2%, hypoalbuminemia 57.2%) and hematological systems (anemia 43.0%, thrombocytopenia 35.2%). HAIC with targeted therapy showed increased adverse events, including characteristic reactions like hand-foot syndrome (48.0%) and hypertension (49.9%). HAIC combined with targeted, and immunotherapy exhibited the highest adverse reaction rates (neutropenia 82.9%, transaminase elevation 97.1%), while HAIC with anti-angiogenic and immunotherapy showed a relatively favorable safety profile. Prospective studies consistently reported higher incidence rates than retrospective studies, suggesting potential underreporting in clinical practice.

Conclusions

Different HAIC-based regimens exhibit distinct safety profiles requiring individualized management approaches. We propose a comprehensive framework for patient selection, monitoring strategies, and AE management. These recommendations aim to optimize treatment outcomes while minimizing adverse impacts on patient quality of life.

Hepatic arterial infusion chemotherapy enhances the efficacy of lenvatinib and PD-1 inhibitors for advanced hepatocellular carcinoma: A meta-analysis and trial sequential analysis

BACKGROUND

Hepatic arterial infusion chemotherapy (HAIC) was an effective treatment for advanced hepatocellular carcinoma (HCC), and its effectiveness in combination with targeted immunotherapy regimens was controversial. This meta-analysis was performed to evaluate the efficacy of adding HAIC to lenvatinib in combination with programmed death-1 (PD-1) inhibitors.

METHODS

Literature related to the efficacy of HAIC in combination with lenvatinib plus PD-1 inhibitors in the treatment of advanced HCC was searched through PubMed, Cochrane Library, Embase, and Web of Science databases. TSA was used to control for the risk of random error and assess whether the meta-analysis evidence was conclusive.

RESULTS

Eight relevant papers with a total of 1244 patients. Compared with the L-P treatment group, the H-L-P treatment group significantly prolonged OS (hazard ratio [HR] 2.11 [95 % confidence interval (CI) 1.82-2.44]; p < 0.001) and PFS (HR 1.91 [95 % CI 1.67-2.17]; p < 0.001) and improved ORR (risk ratio [RR] 2.20 [95 % CI 1.74-2.78]; p < 0.001) and DCR (RR 1.28 [95 % CI 1.15-1.42]; p < 0.001) in patients with advanced HCC. TSA analysis indicated that further trials were unnecessary, preliminary positive results were promptly obtained. Prognostic factor analysis demonstrated that extrahepatic metastasis were common independent risk factor for OS and PFS. The rate of adverse events (AEs) was higher in the H-L-P treatment group than in the L-P treatment group.

CONCLUSION

HAIC combined with lenvatinib plus PD-1 inhibitors markedly extended OS and PFS, particularly in patients without extrahepatic metastases. Furthermore, it markedly enhanced ORR and DCR in patients with HCC.

Advancements in second-line treatment research for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors, characterized by high incidence and mortality rates. Due to its insidious onset, most patients are diagnosed at an advanced stage, often missing the opportunity for surgical resection. Consequently, systemic treatments play a pivotal role. In recent years, an increasing number of drugs have been approved for first-line systemic treatment of HCC. However, their efficacy is limited, and some patients develop drug resistance after a period of treatment. For such patients, there is currently a lack of standard second-line systemic treatment options. This review summarizes the latest advancements in second-line systemic treatment research for HCC patients who have developed resistance to various first-line systemic treatments, aiming to provide more rational and personalized second-line treatment strategies.

Efficacy of radiotherapy combined with hepatic arterial infusion chemotherapy, TKI and ICI for hepatocellular carcinoma with portal vein tumor thrombus: a retrospective cohort study

PURPOSE

This retrospective study was conducted to evaluate the effectiveness and safety of a new combination therapy of radiotherapy (RT), hepatic arterial infusion chemotherapy (HAIC), tyrosine kinase inhibitors (TKI) and immune checkpoint inhibitors (ICI) for hepatocellular carcinoma (HCC) patients involving portal vein tumor thrombus (PVTT).

METHODS

A total of 71 HCC patients with PVTT were retrospectively analyzed: 45 patients were treated by 'HAIC + TKI + ICI' therapy and 26 patients by the new combination therapy. The primary outcomes were overall survival (OS), progression-free survival (PFS), and cumulative survival rate.

RESULTS

The PFS in the 'New combination therapy' group was longer than that in the 'HAIC + TKI + ICI' group (HR 0.459, 95%CI 0.253-0.832; P = 0.008). Meanwhile, the OS in the 'New combination therapy' group was also longer than that in the 'HAIC + TKI + ICI' group (HR 0.420, 95%CI 0.198-0.894; P = 0.024). Compared with 'HAIC + TKI + ICI' group patients, the 'New combination therapy' group patients had higher 1-year PFS rate and 1-year OS rate (P = 0.029; P = 0.015). There was no significant difference in the incidence of adverse events between the two groups.

CONCLUSION

The new combination therapy was an effective and safe non-surgical treatment for HCC patients with PVTT and could be considered a preferred therapy option.

Combining immune checkpoint inhibitors and molecular-targeted agents with hepatic arterial infusion chemotherapy for hepatocellular carcinoma with inferior vena cava and/or right atrium tumor thrombus

BACKGROUND

Hepatocellular carcinoma with inferior vena cava and/or right atrium tumor thrombus (HCC-IVC/RATT) has a poor prognosis and lacks evidence for standard first-line systemic therapy. This study aims to evaluate the effectiveness and safety of three therapeutic regimens in HCC-IVC/RATT: immune checkpoint inhibitors plus molecular-targeted agents (ICI-MTA), hepatic arterial infusion chemotherapy (HAIC), and their combination (ICI-MTA-HAIC).

METHODS

This multicenter retrospective cohort study included consecutive HCC-IVC/RATT who received ICI-MTA-HAIC, ICI-MTA, or HAIC from June 2015 to December 2023. Propensity score matching (PSM) was used to balance baseline characteristics.

RESULTS

A total of 355 patients were included: 209 received ICI-MTA-HAIC, 66 received ICI-MTA, and 80 received HAIC. After PSM, the ICI-MTA-HAIC group showed superior median overall survival (OS) to both the ICI-MTA (18.0 vs. 7.5 months, p < 0.001) and HAIC (18.5 vs. 7.1 months, p < 0.001) groups. The ICI-MTA-HAIC group demonstrated better median progression-free survival (PFS) and objective response rate (ORR) compared to the ICI-MTA (PFS: 9.5 vs. 4.4 months; ORR: 47.0% vs. 21.3%, all p < 0.001) and HAIC (PFS: 9.5 vs. 4.4 months; ORR: 48.8% vs. 21.6%, all p < 0.001) groups. There was no significant difference in OS, PFS, or ORR between the ICI-MTA and HAIC groups (all p > 0.05). Grade 3-4 adverse event rates were 49.8%, 33.3%, and 35.0% for the ICI-MTA-HAIC, ICI-MTA, and HAIC groups, respectively. No unexpected events or treatment-related deaths were observed.

CONCLUSION

ICI-MTA-HAIC was a safe and effective therapy that prolonged the survival of HCC-IVC/RATT compared to ICI-MTA or HAIC.

Advancements in locoregional therapy for advanced hepatocellular carcinoma: Emerging perspectives on combined treatment strategies

Hepatocellular carcinoma (HCC) persists as a leading cause of cancer-related mortality, often diagnosed at advanced stages with limited treatment options. Locoregional therapies (LRTs) are crucial in HCC management, playing significant roles in neoadjuvant and palliative treatments, among others. However, the unique disease background of HCC necessitates multidisciplinary and integrated treatment strategies. The therapeutic landscape for advanced HCC has been significantly broadened by the advent of combined therapies, presenting multiple approaches aimed at improving long-term survival, which remains a critical challenge. This review offers a comprehensive overview of major LRTs for HCC, highlighting recent technological advancements and exploring the challenges and limitations in their application, and presents the latest developments in combination therapies, including combinations between different LRTs and their integration with systemic treatments. Additionally, we outline future directions for the development of integrated treatment modalities for advanced HCC.

Single-Nucleus and Spatial Transcriptome Profiling Delineates the Multicellular Ecosystem in Hepatocellular Carcinoma After Hepatic Arterial Infusion Chemotherapy

Hepatic arterial infusion chemotherapy (HAIC) has emerged as a promising treatment strategy for hepatocellular carcinoma (HCC), but a detailed understanding of the multicellular ecosystem after HAIC treatment is lacking. Here, we collected tumor samples from treatment-naïve primary and post-HAIC HCC, and integrated single-nucleus RNA sequencing with spatial transcriptomics to characterize the tumor ecosystem in the post-HAIC HCC. Increased fractions and enhanced cellular communication of CD4+ T, CD20+ B, and dendritic cell subtypes were identified in post-HAIC tumors. Moreover, it is substantiated that HAIC promoted tertiary lymphoid structures (TLS) formation, and addressed the roles of TLSs as spatial niches of cellular communication. Specifically, intermediate exhausted CD8+ T cells expressing Granzyme-K and PD-1 (PD-1+CD8+ Tex-int) expanded following HAIC and exhibited a functionally antitumor phenotype. PD-1+CD8+ Tex-int accumulated in the TLS vicinity and disseminated throughout the tumor microenvironment, demonstrating potential as an effective biomarker for HAIC-based treatment in HCC. This study provides valuable resources and biological insights in the cellular underpinnings of HAIC treatment.

Clinical Outcomes of Hepatic Arterial Infusion Chemotherapy Plus Lenvatinib and Tislelizumab for Treating Hepatocellular Carcinoma and Type IV Portal Vein Tumor Thrombus

Purpose

To assess the activity and toxicity of hepatic arterial infusion chemotherapy (HAIC)+tislelizumab+lenvatinib (HAIC+tisle+len) in hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT) type IV (Vp4 hCC) in a real-world context.

Methods

Fifty-five patients, with Vp4 hCC receiving HAIC+tisle+len therapy from April 2021 to December 2022, were analyzed retrospectively. Data on patient characteristics, adverse events (AEs), treatment, and survival were collected. Outcomes were disease control rate (DCR), overall response rate (ORR), overall survival (OS), progression-free survival (PFS), and treatment-related AEs (TRAEs).

Results

As of December 20, 2023, the median follow-up was 17.5 months (95% confidence interval [CI]: 14.7-22.5). The ORR was 52.7% (3 complete response [CR], 26 partial response [PR]) as per RECIST v1.1 and 65.5% (12 CR, 24 PR) as per mRECIST. The DCR was 94.5% using both RECIST v1.1 and mRECIST. The median PFS and the median OS were 8.0 months (95% CI: 6.2-12.3) and 16.7 months (95% CI: 12.0-not reached), respectively. Additionally, PFS was independently predicted only by the best tumor response. In patients with the best tumor response (PR or CR), the median PFS was 11.7 months (95% CI: 8.02-not reached) by mRECIST and 15.4 months (95% CI: 7.39-not reached) by RECIST v1.1. Hypertension (14.5%), decreased albumin levels (10.9%) and anorexia (9.1%) were the most frequently observed grade 3-4 TRAEs.

Conclusion

HAIC+tisle+len regimen demonstrated a promising efficacy and favorable safety for patients with HCC and Vp4, providing valuable real-world evidence to complement the trial data for Vp4 hCC.

PD(L)1 Inhibitors Plus Lenvatinib Vs Atezolizumab Plus Bevacizumab Combined With HAIC for Unresectable HCC: A Propensity Score Matching Study

Purpose

To compare the clinical outcomes of different systemic therapies, specifically PD(L)1 inhibitors plus Lenvatinib versus Atezolizumab plus Bevacizumab, when combined with hepatic arterial infusion chemotherapy (HAIC) based on the FOLFOX regimen (oxaliplatin, fluorouracil, and leucovorin) as first line treatment for unresectable hepatocellular carcinoma.

Patients and Methods

This real-world retrospective study enrolled 294 patients with unresectable HCC. All patients received HAIC in combination with either PD(L)1 inhibitors plus Lenvatinib (PLEN-HAIC) or Atezolizumab plus Bevacizumab (AT-HAIC). Propensity score matching (PSM) was performed to balance patient characteristics. The overall response rate (ORR), progression-free survival (PFS), and overall survival (OS) were compared.

Results

After PSM, 80 and 130 patients received AT-HAIC and PLEN-HAIC, respectively. No significant differences were found in ORR between the AT-HAIC and PLEN-HAIC groups (50.0% vs 40.0% per RECIST, p = 0.202; 60.0% vs 57.7% per mRECIST, p = 0.853). Both groups showed similar disease control rates. Median PFS was 14.3 months for PLEN-HAIC versus 8.8 months for AT-HAIC (p = 0.018). Median OS was significantly better in the PLEN-HAIC group (p = 0.045, both not reached). Subgroup analysis revealed that Lenvatinib showed a better OS compared to Bevacizumab when combined with HAIC and PDL1 inhibitors (p = 0.023).

Conclusion

PLEN-HAIC offers significant survival benefits over AT-HAIC in advanced HCC. Given its remarkable efficacy, PLEN-HAIC could be a promising first-line option for unresectable HCC.

Hepatic arterial infusion chemotherapy combined with immune checkpoint inhibitors and molecular targeted therapies for advanced infiltrative hepatocellular carcinoma: a single-center experience

Background

Infiltrative hepatocellular carcinoma (HCC) remains a therapeutic challenge due to its aggressive course and poor prognosis. Hepatic arterial infusion chemotherapy (HAIC) plus immune checkpoint inhibitors (ICIs) and molecular targeted therapies (MTTs) has shown early promise for advanced HCC, but its role in advanced infiltrative HCC is unclear. This study aims to investigate the efficacy and safety of HAIC combined with ICIs and MTTs in the treatment of advanced infiltrative HCC.

Methods

Patients with infiltrative HCC initially treated with HAIC plus ICIs and MTTs were consecutively included at our institution from November 2021 to June 2023. The efficacy evaluation included tumor response, time to response (TTR), duration of response (DOR), progression-free survival (PFS) per RECIST 1.1, and patient survival. Adverse events (AEs) were recorded for safety evaluation.

Results

A total of 27 patients were included and the median follow-up was 15.8 months (range, 4.3-25.9). The best objective response rate (ORR) and disease control rate (DCR) were 70.4% and 88.9%, respectively. The median TTR was 2.8 months (95% confidence interval [CI], 2.6-3.0) and the median DOR was 7.9 months (95% CI, 3.2-12.5). The median PFS was 7.5 months (95% CI, 4.2-10.7), and the median overall survival (OS) was 16.8 months (95% CI, 14.0-19.6), with a 1-year OS rate of 74.1%. No cases of grade 4 or 5 treatment-related adverse events (TRAEs) were observed in this study. Grade 3 TRAEs occurred in 17/27 (63.0%) patients, and the predominant grade 3 treatment-related adverse events were lymphocyte count decreased (18.5%) and neutrophil count decreased (14.8%).

Conclusions

The combination of HAIC plus ICIs and MTTs demonstrated encouraging outcomes and manageable safety concerns for infiltrative HCC.

Prognosis prediction of α-FAtE score for locoregional immunotherapy in hepatocellular carcinoma

Purpose

The α-FAtE score, composed of alpha-fetoprotein, alkaline phosphatase, and eosinophil levels, has been reported as a predictor of prognosis in hepatocellular carcinoma (HCC) patients treated with atezolizumab plus bevacizumab. This study aimed to investigate the predictive ability of α-FAtE score for the efficacy and safety of locoregional immunotherapy as the treatment of HCC patients.

Methods and patients

We conducted a retrospective study of 446 HCC patients at Sun Yat-sen University Cancer Center from January 1st 2019 to January 1st 2023. The predictive performance was evaluated by the concordance index, the area under the receiver operating characteristics curve, the Kaplan-Meier curve and multiple Cox regression analysis.

Results

446 patients were divided into the α-FAtE 0-1 group (n=211) and α-FAtE 2-3 group (n=235). The median progression-free survival(PFS) of the α-FAtE 0-1 group and 2-3 group was 7.3 months (95%CI 6.6-8.7 months), and 12.3 months (95% CI 10.4-14.1 months; P<0.001), respectively. The median overall survival (OS) of the α-FAtE 0-1 group and 2-3 group was 16.3 months (95%CI 13.7-21.5 months) and 34.1 months (95% CI 27.6-NA months; P<0.001), respectively. HCC patients in the α-FAtE 2-3 group had higher complete response (CR) rate and experienced less drug-related adverse events than those in the α-FAtE 0-1 group. Moreover, a lower α-FAtE score was identified as an independent prognostic indicator for both OS and PFS of advanced HCC patients receiving locoregional immunotherapy.

Conclusion

The α-FAtE score is a superior predictor of prognosis in HCC patients receiving locoregional immunotherapy, offering a valuable tool for patient stratification and treatment planning.

Identification of prognostic tumor microenvironment in patients with advanced hepatocellular carcinoma treated with hepatic arterial infusion chemotherapy combined with lenvatinib and PD-1 inhibitors

BACKGROUND

In advanced hepatocellular carcinoma (HCC), the triple combination therapy of hepatic arterial infusion chemotherapy (HAIC) with lenvatinib and programmed cell death protein-1 (PD-1) inhibitors has shown promise as a front-line treatment. This study aimed to explore the tumor microenvironment (TME) characteristics of the population benefiting most from this treatment.

METHODS

The study included 44 patients, with 38 ultimately receiving the HAIC + FOLFOX + lenvatinib + PD-1 inhibitor treatment. Tumor response was evaluated using modified RECIST criteria, classifying patients as responders (complete or partial response) or non-responders (stable or progressive disease). Overall survival (OS), progression-free survival (PFS), and adverse events (AEs) were assessed. Additionally, genetic sequencing and RNA analysis were conducted on biopsy samples to identify TME differences between the two groups.

RESULTS

Among the 38 patients, 22 responded favorably, showing significantly longer median OS (not-reached vs. 8.6 months) and median PFS (15.3 months vs. 2.0 months) compared to non-responders. Common AEs included AST elevation, stomachache, nausea, and hypertension, with limited severe AEs. Genetic analysis revealed no significant differences in DNA features between the groups. However, RNA analysis indicated that responders had a more robust immune status, better drug sensitivity, and increased immune cell infiltration. Notably, higher levels of tumor-infiltrating T lymphocytes were linked to better responses, longer PFS, and OS.

CONCLUSION

The differences in the initial TME of patients, especially in tumor-infiltrating T lymphocytes, may be potential biomarkers for predicting response and prognosis. This finding provides clues to search for biomarkers for this triple combination therapy in advanced HCC.

Prognosis predictors of hepatocellular carcinoma after hepatectomy following conversion therapy

BACKGROUND

Hepatectomy is the optimal treatment for less than 20 % patients with hepatocellular carcinoma (HCC). A combination of hepatic artery infusion chemotherapy and systemic therapy-based conversion therapy provides a chance of resection for those with unresectable HCC. Yet, the prognosis for those successfully conversion resection is still unknown. The study is to determine the factors predicted prognosis of patients after conversion hepatic resection.

METHODS

A total of 343 HCC patients underwent hepatectomy following conversion therapy from August 2018 to April 2023. Univariate and multivariate analysis were used to screen for independent factors affecting patients' prognosis.

RESULTS

One hundred and fifty-seven (45.8 %) patients developed recurrence or metastasis at a median time of 16.7 months (95 % CI 12.4-21.0 months) from hepatectomy. Univariate and multivariate analysis identified tumor number, alpha fetoprotein (AFP) response, tumor response, and successful downstaging were independent recurrent-free survival related predictors. Albumin bilirubin (ALBI) score and AFP response were independent death related predictors.

CONCLUSIONS

Clinical parameters reflecting the depth of conversion therapy response, were promising in predicting prognosis for HCC patients after conversion hepatic resection.

Hepatic arterial chemotherapy infusion combined with tyrosine kinase inhibitors and PD-1 inhibitors for advanced hepatocellular carcinoma with high risk: a propensity score matching study

OBJECTIVE

To ascertain the therapeutic efficacy and safety of FOLFOX (oxaliplatin, fluorouracil, and leucovorin)-based hepatic arterial infusion chemotherapy combined with tyrosine kinase inhibitors (TKI) and programmed cell death protein-1 inhibitors (PD-1 inhibitors) (triple therapy), as a first-line treatment in high-risk advanced hepatocellular carcinoma (aHCC with Vp4 portal vein invasion or/and tumor diameter ≥10 cm).

METHODS

This retrospective multicenter study included 466 high-risk aHCC patients treated with either triple therapy ( n =245) or dual therapy (TKI and PD-1 inhibitors, n =221). The overall survival, progression-free survival, objective response rate, and safety were compared between the two groups. Propensity score matching was performed to reduce bias between the two groups.

RESULTS

After propensity score matching (1:1), 194 patients in each group were analyzed. The triple-therapy group showed a longer median overall survival (24.6 vs. 11.9 months; HR=0.43, P <0.001) and a longer median progression-free survival (10.0 vs. 7.7 months; HR=0.68, P =0.002) than the dual-therapy group. The survival rates at 6, 12, and 24 months were 94.2, 71.0, and 50.8% for triple therapy and 75.9, 49.9, and 26.8% for dual therapy. The objective response rate in the triple-therapy group was significantly higher (57.7 vs. 28.9%, P <0.001). In the triple-therapy group, more patients converted to non-high-risk (68.0 vs. 36.6%, P <0.001) and received salvage liver resection or ablation after downstaging conversion (16.5% vs. 9.2%, P =0.033). The grade 3/4 adverse events were 59.2 and 47.4% in the triple-therapy group and dual-therapy group, respectively ( P =0.022).

CONCLUSION

FOLFOX-based hepatic arterial infusion chemotherapy plus TKI and PD-1 inhibitors significantly improve survival prognosis compared with TKI plus PD-1 inhibitors. This is a potential first-line treatment for high-risk aHCC, with a relatively controlled safety profile.

Optimal candidates and surrogate endpoints for HAIC versus Sorafenib in hepatocellular carcinoma: an updated systematic review and meta-analysis

BACKGROUND AND AIMS

Hepatic artery infusion chemotherapy (HAIC) has been a long-standing intervention for hepatocellular carcinoma (HCC). Despite positive clinical outcomes, its inclusion in guidelines remains limited due to a lack of evidence-based support. This study aims to identify optimal target populations for HAIC and validate associations between intermediate endpoints with overall survival (OS).

METHODS

Following PRISMA guidelines, a comprehensive search was conducted in PubMed, Embase, Cochrane Library, and Web of Science. The primary search strategy was based on medical subject headings terms (MeSH) using 'Hepatic arterial infusion chemotherapy', 'HAIC', 'Sorafenib', 'Nexavar', 'hepatocellular carcinoma', 'HCC', 'Liver cancer', combined with free text words. Data extraction, quality assessment, and analysis were performed according to preregistered protocol.

RESULTS

A total of 26 studies, 6456 HCC patients were included for analysis (HAIC, n =2648; Sorafenib, n =3808). Pooled outcomes revealed that Sorafenib demonstrated better OS only in patients who were refractory to trans-arterial chemoembolization (TACE) (HR=1.32, 95% CI [1.01-1.73]), in other subgroups or overall HCC population HAIC consistently outperformed Sorafenib in patients' survival. Radiologically, higher response rates in the HAIC group does not necessarily translate into survival improvement, but the hazard ratios (HRs) of 1-year-OS (R 2 =0.41, P =0.0044) and 1-year-progression free survival (1y-PFS) (R 2 =0.77, P =0.0002) strongly correlated with the patients OS. Meanwhile, larger tumour size (HR=1.86, 95% CI [1.12-3.1, 95%), heavier tumour burden (HR=2.32, 95% CI [1.33-4.02), existence of MVI or EHS (HR=1.65, 95% CI [1.36-2]; HR=1.60, 95% CI [1.19-2.14]), and AFP >400 ng/ml (HR=1.52, 95% CI [1.20-1.92]) were identified as independent risk factors for OS, while HAIC treatment (HR=0.54, 95% CI [0.35-0.82]) and lower BCLC stage (HR=0.44, 95% CI [0.28-0.69]) were potential protective factors for HCC patients.

CONCLUSION

HAIC monotherapy appears noninferior to Sorafenib in HCC treatment, with potential benefits in specific subgroups. The robust correlation between 1y-OS/1y-PFS and OS, alongside identified risk and protective factors from the present study, offers valuable insights for designing future large prospective studies in this field.

Lenvatinib and immune-checkpoint inhibitors in hepatocellular carcinoma: mechanistic insights, clinical efficacy, and future perspectives

Lenvatinib is a multi-target tyrosine kinase inhibitor widely used in the treatment of hepatocellular carcinoma (HCC). Its primary mechanism of action involves inhibiting signal pathways such as vascular endothelial growth factor receptors (VEGFR) and fibroblast growth factor receptors (FGFR), thereby reducing tumor cell proliferation and angiogenesis and affecting the tumor's immune microenvironment. In the treatment of liver cancer, although lenvatinib monotherapy has shown good clinical effect, the problem of drug resistance is becoming more and more serious. This resistance may be caused by a variety of factors, including genetic mutations, signaling pathway remodeling, and changes in the tumor microenvironment. In order to overcome drug resistance, the combination of lenvatinib and other therapeutic strategies has gradually become a research hotspot, and it is worth noting that the combination of lenvatinib and immune checkpoint inhibitors (ICIs) has shown a good application prospect. This combination not only enhances the anti-tumor immune response but also helps improve therapeutic efficacy. However, combination therapy also faces challenges regarding safety and tolerability. Therefore, studying the mechanisms of resistance and identifying relevant biomarkers is particularly important, as it aids in early diagnosis and personalized treatment. This article reviews the mechanisms of lenvatinib in treating liver cancer, the mechanisms and efficacy of its combination with immune checkpoint inhibitors, the causes of resistance, the exploration of biomarkers, and other novel combination therapy strategies for lenvatinib. We hope to provide insights into the use and research of lenvatinib in clinical and scientific settings, offering new strategies for the treatment of liver cancer.

Hepatic arterial infusion chemotherapy (HAIC) combined with Tislelizumab and Lenvatinib for unresectable hepatocellular carcinoma: a retrospective single-arm study

PURPOSE

We aimed to explore the curative effects of hepatic arterial infusion chemotherapy (HAIC) combined with Tislelizumab and Lenvatinib on unresectable hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

From September 2021 to September 2023, 42 patients with unresectable HCC who were treated in the First Affiliated Hospital of Chongqing Medical University were enrolled in this retrospective single-arm study. They received HAIC combined with Tislelizumab and lenvatinib. Baseline characteristics, laboratory indicators before and after treatment, and imaging findings were collected from medical records. The primary endpoint was objective response rate (ORR), and the secondary endpoints included disease control rate (DCR), overall survival (OS), progression-free survival (PFS), and safety indicators.

RESULTS

A total of 199 HAIC treatments were performed, with a median of 5.5 times (3.75-6.0 times). Based on the mRECIST and RECIST1.1 criterion, the ORR was 71.4% and 57.1%, the DCR was 92.9% and 92.9%. Up to the follow-up date of October 1, 2024, the median PFS was 14.0 months (95% CI, 11.6-16.4 months), and the median OS was 26.0 months.The incidence of any grade of adverse events was 97.6%. The most commonly reported treatment-related grade 3-4 adverse events included thrombocytopenia (28.6%), elevated total bilirubin (19%), and abdominal pain (16.7%). There was no treatment-related death.

CONCLUSION

For unresectable HCC, HAIC combined with tirelizumab and lenvatinib has good anti-tumor efficacy and acceptable adverse reactions.

Promising PD-1 antagonists for liver cancer: an evaluation of phase II and III results

INTRODUCTION

Hepatocellular carcinoma (HCC), the most common primary liver cancer, is a major cause of cancer-related morbidity and mortality. Limited treatment options for advanced stages highlight the need for effective therapies.

AREAS COVERED

This review explores immune checkpoint inhibitors (ICIs), specifically PD-1, PD-L1, and CTLA-4 inhibitors, as emerging treatments for advanced HCC. It discusses data from phase II and III trials evaluating ICI combinations with tyrosine kinase inhibitors (TKIs), anti-angiogenic agents, and locoregional treatments like Transarterial Chemoembolization (TACE). Clinical outcomes, including progression-free survival and response rates, were analyzed alongside the incidence and management of immune-related adverse events (irAEs). A systematic review approach ensured comprehensive, high-quality study inclusion.

EXPERT OPINION

ICI-based therapies and their combinations are transforming advanced HCC treatment, offering improved outcomes and potential survival benefits. However, these therapies need optimization in sequencing and selection, particularly considering variations in liver function and disease stage. Effective management of adverse effects is critical to maximize clinical benefits. Further research is required to develop personalized strategies, tailoring treatments to patient-specific factors and enhancing safety and effectiveness in HCC management.

Real-world status, efficacy and prognosis analysis of first-line treatment for unresectable hepatocellular carcinoma in patients treated at multiple centres

OBJECTIVE

To present the real-world status and explore the predictors of the efficacy and prognosis of first-line treatment for unresectable hepatocellular carcinoma (uHCC).

METHODS

Real-world data of uHCC patients who underwent first-line treatment at 4 hospitals in Northern Anhui, China, from July 2019 to December 2022 were retrospectively collected. The clinicopathological features, haematological indicators, including superoxide dismutase (SOD) and vascular endothelial growth factor-A (VEGF-A), efficacy and safety data were analysed.

RESULTS

A total of 153 patients were enrolled and most of them treated with targeted therapy combined with immunotherapy (TI). Compared to patients treated with TI, patients who were administrated with TI plus locoregional therapy (TIL) showed longer median progression-free survival (mPFS) and median overall survival (mOS) times (both p < 0.05), with manageable safety profiles. Moreover, compared to patients with low baseline serum levels of SOD, patients with high baseline serum SOD levels had a better treatment efficacy and had longer mPFS and mOS times (all p < 0.05). Subgroup analyses indicated that patients with low SOD levels had longer mPFS times when receiving TIL than when receiving TI (p = 0.005), but, among patients with high SOD levels, their prognoses were not substantially different between TIL and TI (p > 0.05). Additionally, patients in the low-VEGF-A group had a longer mOS time than patients in the high-VEGF-A group (p = 0.004). In comparison with TI, TIL can improve the survival time among patients with high VEGF-A levels but not among patients with low VEGF-A levels.

CONCLUSIONS

TI was the most commonly first-line systemic therapy for uHCC patients, with better efficacy and outcomes when combined with locoregional therapy in a certain population. Baseline serum SOD and VEGF-A were found to be potential predictive biomarkers for decision-making, treatment response, and outcome in patients with uHCC in the primary care setting.

Hepatic arterial infusion chemotherapy combined with systemic therapy sequentially or simultaneously for advanced hepatocellular carcinoma

BACKGROUND AND AIMS

The goal of this study was to compare the efficacy and safety of hepatic arterial infusion chemotherapy (HAIC) combined with targeted therapy and PD-(L)1 blockade (triple therapy), either sequentially (SE) or simultaneously (SI), in the treatment of Barcelona Clinic Liver Cancer (BCLC) stage C hepatocellular carcinoma (HCC).

APPROACH AND RESULTS

From January 1, 2018, to June 1, 2022, 575 patients with BCLC stage C HCC who underwent SE or SI triple therapy were retrospectively enrolled. Propensity score matching (PSM; 1:1) was performed to eliminate possible confounder imbalances across cohorts. We used the Kaplan-Meier method and a log-rank test to compare the overall survival (OS) and progression-free survival (PFS) rates between the SI and SE groups. The tumor response and the incidence of adverse events (AEs) were reported. After PSM, 182 patients in each of the two groups were matched. The median OS in the SI group was significantly longer than that in the SE group (28.8 vs. 16.1 months; P = 0.002), and the median PFS was significantly improved in the SI versus SE group (9.6 vs. 7.0 months; P = 0.01). The objective response rate based on the mRECIST was higher in the SI group (58% vs. 37%; P < 0.001). The total incidences of grade 3-4 AEs were 111/182 (60.9%) and 128/182 (70.3%) in the SE and SI groups, respectively. No grade 5 AEs were reported in either group.

CONCLUSIONS

Simultaneous HAIC plus targeted therapy and PD-(L)1 blockade significantly improved outcomes compared to the sequential regimen in patients with BCLC stage C HCC, with no unexpected AEs.

CLINICAL RELEVANCE STATEMENT

The patients who received hepatic arterial infusion chemotherapy combined with targeted therapy and PD-(L)1 blockade simultaneously have a better prognosis than those who received it sequentially.

Silk Fibroin-Based Lenvatinib Nanomedicine with Conformation Tunability for Systemic Treatment of Hepatocellular Carcinoma

Multitarget tyrosine kinase inhibitors (TKIs) serve as first-line therapeutics in the systemic treatment of hepatocellular carcinoma (HCC), yet their clinical effectiveness is hampered by suboptimal pharmacokinetics and bioavailability. There is a critical need to enhance the circulation, tumor targeting, and infiltration of TKIs. In this context, we developed a silk fibroin (SF)-based nanomedicine that exploits the chemical versatility and conformation tunability of SF. Folic acid (FA) with affinity toward HCC cells is utilized to functionalize SF, simultaneously aiding in the pH-sensitive β-sheet transitions of SF. This dynamic conformation behavior is key to improving the nanomedicine's circulation, biological adhesion, and tumor localization. By encapsulating Lenvatinib (Leva) TKI, the nanomedicine exhibits tumor-targeted accumulation and potent inhibition on HCC cell survival and angiogenesis, thereby amplifying Leva's bioavailability and therapeutic impact. Owing to SF's low immunogenicity and high reproducibility, this SF-based approach for TKI delivery holds substantial promise for advancing HCC systemic therapy.

Clinical Effectiveness and Safety of Transarterial Chemoembolization: Hepatic Artery Infusion Chemotherapy Plus Tyrosine Kinase Inhibitors With or Without Programmed Cell Death Protein-1 Inhibitors for Unresectable Hepatocellular Carcinoma-A Retrospective Study

BACKGROUND

Locoregional treatment with transarterial chemoembolization (TACE) or hepatic artery infusion chemotherapy (HAIC) and systemic targeted immunotherapy with tyrosine kinase inhibitors (TKI) and programmed cell death protein-1 (PD-1) inhibitors in the treatment of unresectable hepatocellular carcinoma (uHCC) have achieved promising efficacy. The retrospective study aimed to evaluate the efficacy and safety of TACE and HAIC plus TKI with or without PD-1 for uHCC.

PATIENTS AND METHODS

From November 2020 to February 2024, the data of 44 patients who received TACE-HAIC + TKI + PD-1 (THKP group) and 34 patients who received TACE-HAIC + TKI (THK group) were retrospectively analyzed. Primary outcomes were overall survival (OS) and progress-free survival (PFS), and secondary outcomes were objective response rate (ORR), disease control rate (DCR), conversion rates, and adverse events (AEs).

RESULTS

A total of 78 patients were recruited in our single-center study. The patients in THKP group had prolonged median OS [25 months, 95% confidence interval (CI) 24.0-26.0 vs 18 months, 95% CI 16.1-19.9; p = 0.000278], median PFS [16 months, 95% CI 14.1-17.9 vs 12 months 95% CI 9.6-14.4; p = 0.004] and higher ORR (38.6% vs 23.5%, p = 0. 156) and DCR (88.6% vs 64.7%, p = 0.011) compared with those in THK group. Multivariate analysis showed that treatment option and alpha-fetoprotein (AFP) level were independent prognostic factors of OS and PFS. The frequency of AEs were similar between the two groups.

CONCLUSIONS

The THKP group had better efficacy for uHCC than the THK group, with acceptable safety.

Prognostic Evaluation of Conversion Therapy following Hepatic Arterial Infusion Chemotherapy or Immunotherapy in Patients with Advanced or Transarterial Chemoembolization Unsuitable Intermediate-Stage Hepatocellular Carcinoma: A Retrospective Cohort Study

INTRODUCTION

Patients with advanced-stage or intermediate-stage hepatocellular carcinoma (HCC) unsuitable for transarterial chemoembolization (TACE) had poor prognoses. Recent advancements in hepatic arterial infusion chemotherapy (HAIC) and immune checkpoint inhibitors (ICIs) have demonstrated higher tumor response rates, which improved overall survival (OS). HAIC achieves an OS rate of approximately 14.5-15.3 months with a 39.1-42.5% tumor response rate. In comparison, ICIs have a 12-14 month OS rate with a 26-33% tumor response rate. Given these promising responses, this study evaluates the efficacy of conversion therapy with curative intent following HAIC or ICIs, focusing on survival outcomes.

METHODS

We retrospectively analyzed 80 patients with advanced or TACE-unsuitable intermediate HCC. Patients completed two HAIC or four ICI cycles, followed by Response Evaluation Criteria in Solid Tumors (RECIST) criteria imaging. Based on demographics, cirrhosis status, Barcelona Clinic Liver Cancer classification (BCLC) stage, treatment responses, and treatment modality, survival impacts were analyzed. OS was compared between HAIC and immunotherapy groups. The effect of conversion therapy with curative intent on survival outcomes was analyzed using a Cox regression model.

RESULTS

Among the 80 patients, 26 achieved positive response (CR/PR) with HAIC or ICIs, and 9 of them subsequently underwent conversion therapy with curative intent. Key prognostic factors included Child-Pugh stage B versus A (HR = 2.21, p = 0.041), BCLC stage C versus B (HR = 4.38, p = 0.011), and elevated alpha-fetoprotein levels (HR = 5.02, p < 0.001). Positive responders saw substantial survival benefits (HR = 0.26, p = 0.001). Patients undergoing conversion therapy exhibited significantly enhanced survival. Median OS was 13.58 months with standard therapy, while the curative intent surgery group did not reach the median OS (p = 0.002). For CR/PR patients, 48-month survival was 75.0% for the curative surgery group versus 38.0% for standard treatment.

CONCLUSION

Conversion therapy with curative intent following HAIC or ICIs might enhance survival in patients with advanced or TACE-unsuitable intermediate-stage HCC.

FOLFOX-Based Hepatic Arterial Infusion Chemotherapy with Sequential Drug-Eluting Bead Transarterial Chemoembolization for Unresectable Large Hepatocellular Carcinoma: A Single-Center Retrospective Cohort Study

Background

For patients with large unresectable hepatocellular carcinoma (HCC), the effectiveness of conventional transarterial chemoembolization (TACE) remains suboptimal, which necessitates the administration of substantial volumes of chemotherapy drugs and lipiodol, thereby increasing the risk of liver failure and other chemotherapy-related complications. Therefore, we devised a strategy of initial hepatic arterial infusion chemotherapy (HAIC) followed by sequential drug-eluting bead TACE (DEB-TACE). In our treatment design, a lower tumor burden after HAIC facilitated complete embolization of tumor vasculature, and the use of less amount of embolic agents reduced the incidence of liver failure and embolization syndromes.

Methods

This retrospective study evaluated consecutive patients with unresectable large HCC with a maximum tumor diameter of ≥7 cm who received FOLFOX-HAIC combined with sequential DEB-TACE from April 2019 to February 2024. Efficacy was evaluated using the objective response rate (ORR), overall survival (OS), and progression-free survival (PFS); and safety was assessed using the frequency of key adverse events (AEs).

Results

Among the 76 patients included, the median maximum tumor diameter was 12.4 cm (range, 7.0-23.4 cm). The overall ORRs based on mRECIST and RECIST 1.1 criteria were 94.1% and 51.5%, respectively. The median OS was 28.1 months (95% CI, 22.7-33.4), and the median PFS was 11.7 months (95% CI, 7.7-15.8). All patients experienced AEs, but only 18.4% experienced grade 3 or 4 AEs, there was no treatment-related mortality.

Conclusion

In this single-center, retrospective study, our results suggested that FOLFOX-HAIC with sequential DEB-TACE demonstrated promising efficacy and safety for patients with unresectable HCC with a maximum tumor diameter of ≥7 cm.

Chinese Expert Consensus on the Whole-Course Management of Hepatocellular Carcinoma (2023 Edition)

Background: Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in China. Most HCC patients have the complications of chronic liver disease and need overall consideration and whole-course management, including diagnosis, treatment, and follow-up. To develop a reasonable, long-term, and complete management plan, multiple factors need to be considered, including the patient’s general condition, basic liver diseases, tumor stage, tumor biological characteristics, treatment requirements, and economic cost. Summary: To better guide the whole-course management of HCC patients, the Chinese Association of Liver Cancer and the Chinese Medical Doctor Association has gathered multidisciplinary experts and scholars in relevant fields to formulate the “Chinese Expert Consensus on The Whole-Course Management of Hepatocellular Carcinoma (2023).” Key Messages: This expert consensus, based on the current clinical evidence and experience, proposes surgical and nonsurgical HCC management pathways and involves 18 recommendations, including perioperative treatment, systematic treatment combined with local treatment, conversion treatment, special population management, symptomatic support treatment, and follow-up management.

Chinese Expert Consensus on the Combination of Targeted Therapy and Immunotherapy with Locoregional Therapy for Intermediate/Advanced Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a major cause of cancer-related mortality; it ranks as the second most common cause of cancer deaths in China. Most HCC patients are first diagnosed at an advanced stage. In recent years, targeted therapy combined with immunotherapy has become the preferred regimen for systemic treatment of intermediate-advanced HCC, while targeted therapy combined with immunotherapy plus local treatment could further improve the efficacy in many clinical studies. To better guide the clinical treatment for effective and safe combination therapy, our interdisciplinary panel on the treatment of intermediate-advanced HCC comprising hepatologists, hepatobiliary surgeons, oncologists, radiologists, interventional radiologists, and traditional Chinese medicine physicians have formulated this consensus based on current clinical studies and clinical medication experience for reference. The consensus contained 15 recommendations, including the applicable population and management, local treatment selection, conversion strategy, treatment strategy after tumor progression and management of common adverse reactions.

Hepatic arterial infusion chemotherapy plus camrelizumab and apatinib for advanced hepatocellular carcinoma

BACKGROUND AND AIMS

There is limited information on combination of hepatic arterial infusion chemotherapy (HAIC) and systemic therapy for advanced hepatocellular carcinoma (Ad-HCC). We aim to compare the efficacy and safety of HAIC plus camrelizumab (a PD-1 inhibitor) and apatinib (an VEGFR-2 inhibitor) versus camrelizumab and apatinib for Ad-HCC.

METHODS

From April 2019 to October 2022, 416 patients with Ad-HCC who received either HAIC plus camrelizumab and apatinib (TRIPLET protocol, n = 207) or camrelizumab and apatinib (C-A protocol, n = 209) were reviewed retrospectively. The propensity score matching (PSM) was used to reduce selective bias. Overall survival (OS) and progression-free survival (PFS) were compared using the Kaplan-Meier method with the log-rank test. Cox regression analyses of independent prognostic factors were evaluated.

RESULTS

After PSM 1:1, 109 patients were assigned to two groups. The median OS of not reached in the TRIPLET group was significantly longer than that of 19.9 months in the C-A group (p < 0.001), while in the TRIPLET group, the median PFS of 11.5 months was significantly longer than that of 9.6 months in the C-A group (p < 0.001). Multivariate analyses showed that the factors significantly affected the OS were CTP grade, tumor number > 3, and TRIPLET treatment (p < 0.001). Grade 3/4 adverse events occurred at a rate of 82.1% vs. 71.3% in TRIPLET and C-A groups, respectively.

CONCLUSION

The TRIPLET protocol has promising survival benefits in the management of patients with Ad-HCC, with acceptable safety.

TRAIL REGISTRATION

The study has been retrospectively registered at Chinese Clinical Trial Registry ( https://www.chictr.org.cn/ , ChiCTR2300075828).

Sequential vs. concurrent systemic therapies in combination with FOLFOX-HAIC for locally advanced hepatocellular carcinoma: a single-center, real-world cohort study

BACKGROUND

Tri-combination therapy based on hepatic arterial infusion chemotherapy (HAIC) of infusion fluorouracil, leucovorin, and oxaliplatin (FOLFOX-HAIC) plus immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs) for the locally advanced hepatocellular carcinoma (HCC) patients have been proven effective. However, whether it was best for these HCC patients to start with the most potent therapeutic pattern was still under debate. This retrospective study evaluated the efficacy and safety of FOLFOX-HAIC combined with systemic therapies in the patterns of sequential and concurrent schedules.

METHODS

This real-world study included 117 unresectable HCC patients who initially received either FOLFOX-HAIC monotherapy (HAIC group, n = 44) or concurrent ICIs and TKIs (ConHAIC group, n = 73) from March 2020 and June 2022, during the period of FOLFOX-HAIC monotherapy in HAIC group, patients in the HAIC group (n = 30) experienced progressive disease (PD) would have their treatment pattern converted from the FOLFOX-HAIC monotherapy to the combination of FOLFOX-HAIC plus ICIs and TKIs sequentially (SeqHAIC group). The progression-free survival (PFS) and overall survival (OS), as primary outcomes, were compared between patients in the SeqHAIC and ConHAIC groups.

RESULTS

The median follow-up time of the SeqHAIC group was 24.92 months (95% CI, 12.74-37.09 months) and of the ConHAIC group was 17.87 months (95% CI, 16.85-18.89 months) and no significant difference was observed in both PFS (HR, 1.572; 95% CI, 0.848-2.916; p = 0.151) and OS (HR, 1.212; 95% CI, 0.574-2.561; p = 0.614) between the SeqHAIC and the ConHAIC groups. As for the tumor responses, there was no significant difference between the two groups regarding tumor responses, overall response rates (p = 0.658) and disease control rates (p = 0.641) were 50.0%, 45.2%, and 83.3%, 89.0% for the SeqHAIC and the ConHAIC groups, respectively.

CONCLUSION

Our study revealed that sequential systemic ICIs and TKIs in combination with FOLFOX-HAIC provides similar long-term prognosis and better tolerability compared to concurrent therapy for locally advanced HCC patients. Prospective studies with a larger sample size and longer follow-up are required to validate these findings.

Efficacy and safety of first-line treatments for advanced hepatocellular carcinoma patients: a systematic review and network meta-analysis

Background

The first-line treatment for advanced hepatocellular carcinoma has evolved significantly. This study aimed to identify the most beneficial regimen.

Methods

A systematic search was conducted from July 2012 to August 2024 across the following four databases: PubMed, Embase, Cochrane Library, and ClinicalTrials.gov. This search focused on phase III prospective randomized controlled trials that compared first-line treatment for advanced hepatocellular carcinoma.

Results

Seventeen studies involving 10322 patients were included in this network meta-analysis. Of the studies we included, twelve studies were global multicenter clinical studies, four were initiated in China, and one was initiated in Korea. The results of our statistical analysis suggest that Hepatic artery infusion chemotherapy with oxaliplatin plus fluorouracil (HAIC-FO) demonstrated significant overall survival (OS) benefits compared with most treatments, including various immune checkpoint inhibitors (ICIs) and anti-vascular endothelial growth factor tyrosine kinase inhibitors (VEGF-TKIs). In terms of OS, HAIC had shown similar efficacy with sorafenib plus FOLFOX (HR, 0.88; 95% CI: 0.37-2.09) and transcatheter arterial chemoembolization (TACE) combined with lenvatinib (HR, 0.69; 95% CI: 0.30-1.56). Notably, immune-related treatments, such as ICIs combined with anti-VEGF therapies, also showed improved OS compared with anti-VEGF-TKIs alone. In terms of progression-free survival (PFS), HAIC-FO outperformed anti-VEGF-TKI monotherapy, ICI monotherapy, and several ICI combinations. However, it was not superior to lenvatinib plus TACE or lenvatinib plus pembrolizumab. Based on the Surface Under the Cumulative Ranking Curve (SUCRA) values, HAIC-FO was ranked the most effective in terms of OS (SUCRA = 0.961) and objective response rate (ORR) (SUCRA = 0.971). The results of the subgroup analysis suggested that HAIC-FO achieved the best OS benefit in the macrovascular invasion (MVI) and extrahepatic spread (EHS) subgroup (SUCRA = 0.99) and that tremelimumab combined with durvalumab achieved the best OS benefit in the Asian subgroup (SUCRA = 0.88).

Conclusion

This systematic review and network meta-analysis suggest that HAIC-based therapies may become a potential first-line treatment option for advanced HCC, especially for patients in Mainland China with MVI and EHS. Additionally, immune-related treatments may be more suitable for Asian populations.

Roles of clinical application of lenvatinib and its resistance mechanism in advanced hepatocellular carcinoma (Review)

Lenvatinib (LEN) is a multi-target TKI, which plays a pivotal role in the treatment of advanced hepatocellular carcinoma (HCC). The inevitable occurrence of drug resistance still prevents curative potential and is deleterious for the prognosis, and a growing body of studies is accumulating, which have devoted themselves to unveiling its underlying resistance mechanism and made some progress. The dysregulation of crucial signaling pathways, non-coding RNA and RNA modifications were proven to be associated with LEN resistance. A range of drugs were found to influence LEN therapeutic efficacy. In addition, the superiority of LEN combination therapy has been shown to potentially overcome the limitations of LEN monotherapy in a series of research, and a range of promising indicators for predicting treatment response and prognosis have been discovered in recent years. In this review, we summarize the latest developments in LEN resistance, the efficacy and safety of LEN combination therapy as well as associated indicators, which may provide new insight into its resistance as well as ideas in the treatment of advanced HCC.

Hepatic Arterial Infusion Chemotherapy Combined Lenvatinib and PD-1 Inhibitor Showed Improved Survival for Infiltrative Hepatocellular Carcinoma: A Multicenter Cohort Study

Purpose

Lenvatinib and programmed cell death protein-1 (PD-1) inhibitor on infiltrative hepatocellular carcinoma (HCC) have obtained demonstrated efficacy and still need improvement. Hepatic arterial infusion chemotherapy (HAIC) has shown promising results for advanced HCC. This study aimed to compare the efficacy of HAIC combined Lenvatinib and PD-1 inhibitor versus Lenvatinib combined PD-1 inhibitor for infiltrative HCC.

Patients and Methods

A total of 232 patients were enrolled. There were 114 patients received Lenvatinib combined PD-1 inhibitor (Len+PD-1 group) and 118 patients received HAIC combined Lenvatinib and PD-1 inhibitor (HAIC+Len+PD-1 group). Overall survival (OS), progression-free survival (PFS) and safety of patients were compared between the two groups by propensity score-matching (PSM).

Results

The 6-, 12-, and 24-month OS rates were 93.8%, 65.1% and 13.4% in Len+PD-1 group, and 100%, 77.3% and 32.1% in HAIC+Len+PD-1 group, respectively. The 3-, 6-, and 12-month PFS rates were 86.4%, 45.7% and 14.1% in Len+PD-1 group, and 95.1%, 59.3% and 25.9% in HAIC+Len+PD-1 group, respectively. The HAIC+Len+PD-1 group had obviously better survival than the Len+PD-1 group both in OS (P=0.002) and PFS (P=0.004). Subgroup analysis revealed that OS in patients with metastasis was improved with HAIC+Len+PD-1 treatment. Patients with alpha-fetoprotein (AFP) response after treatment showed better survival than the non-response. In addition, HAIC+Len+PD-1 group showed manageable adverse events (AEs).

Conclusion

Patient with infiltrative HCC, HAIC+Len+PD-1 treatment had longer OS and PFS than Len+PD-1 treatment. Early AFP response was an effective indicator of better survival and tumor response to therapy.

Survival Benefit of Lenvatinib Plus PD-1 Inhibitor with or Without HAIC in Advanced Hepatocellular Carcinoma Beyond Oligometastasis: a Multicenter Cohort Study

Purpose

The outcome between Lenvatinib plus programmed cell death protein-1 (PD-1) inhibitor and Lenvatinib in HCC beyond oligometastasis was unclear. In this multicenter, we compared the prognosis of Lenvatinib plus PD-1 inhibitor with Lenvatinib in HCC beyond oligometastasis.

Patients and Methods

A total of 296 patients from six institutions were included. The patients were divided into two groups: (a) concurrent Lenvatinib plus PD-1 inhibitor treatment (Len+PD-1 group) and (b) Lenvatinib monotherapy (Len group). The primary endpoint was overall survival (OS), the second endpoint was progression-free survival (PFS) and efficacy.

Results

The median OS was 20.1 ± 1.2 (17.7-22.5) months and 15.7 ± 1.5 (12.8-18.6) months in the Len+PD-1 and Len groups, respectively. The 12-, 24-, and 36-month OS rates were 79.1%, 39.4%, and 10.7% in the Len+PD-1 group, and 76.3%, 29.7%, and 0% in the Len group, respectively. The OS and PFS rates of the Len+PD-1 group were significantly longer compared with the Len group (hazard ratio [HR], 0.88; 95% confidence index [CI], 0.49-0.94; P = 0.021) and (HR, 0.66; 95% CI, 0.50-0.87; P = 0.003). A subgroup analysis revealed that OS (HR, 0.57; 95% CI, 0.36-0.90; P = 0.016) was improved between the Len+PD-1 and Len groups with hepatic artery infusion chemotherapy (HAIC) treatment, whereas OS (HR, 1.11; 95% CI, 0.68-1.80; P = 0.689) was similar between the Len and Len+PD-1 groups without HAIC.

Conclusion

Lenvatinib combined with PD-1 inhibitor significantly improves the survival of HCC beyond oligometastasis. For patients with HAIC, there was obviously significance between Len and Len+PD-1 groups.

Clinical Therapy: HAIC Combined with Tyrosine Kinase Inhibitors and Programmed Cell Death Protein-1 Inhibitors versus HAIC Alone for Unresectable Hepatocellular Carcinoma

Purpose

The majority of new diagnoses of hepatocellular carcinoma (HCC) still pertain to unresectable cases. Currently, the combination therapy of tyrosine kinase inhibitors (TKIs) and programmed cell death protein-1 (PD-1) inhibitors has become the mainstream treatment. According to multiple clinical guidelines, it is strongly advised to consider local therapy as the primary treatment choice for uHCC. This research was conducted to examine the safety and effectiveness of combining hepatic arterial infusion chemotherapy (HAIC) with TKIs and PD-1 inhibitors for the treatment of uHCC.

Methods

Between 2015 and 2020, 208 HCC patients received HAIC alone or HAIC in combination with TKIs and PD-1 inhibitors. The overall survival(OS), and progression-free survival(PFS) and the best treatment response were compared between the two treatment groups. Propensity score matching (PSM)was used to minimize confounding bias.

Results

Among the enrolled patients, 116 patients (55.8%) received combination therapy, while 92 patients (44.2%) received HAIC alone. The baseline characteristics were similar between the two groups. After PSM, 82 pairs of well-matched liver cancer patients were selected; the overall response rate in the combination group trended better than that in the HAIC alone group. The hazard ratios (HRs) for OS and PFS of the combination approach compared to the HAIC-alone approach were 0.47 (95% CI, 0.322-0.687; p<0.001) and 0.58 (95% CI, 0.397-0.848; p=0.005), respectively.

Conclusion

For uHCC patients, combination therapy can provide better OS and PFS compared to HAIC alone.

Progress of immune checkpoint inhibitors in the treatment of advanced hepatocellular carcinoma

Among primary liver cancers, hepatocellular carcinoma is the most common pathological type. Its onset is insidious, and most patients have no obvious discomfort in the early stage, so it is found late, and the opportunity for surgical radical treatment is lost, resulting in a poor prognosis. With the introduction of molecular-targeted drugs represented by sorafenib, patients with middle- and late-stage liver cancer have regained the light of day. However, their therapeutic efficacy is relatively low due to the limited target of drug action, toxic side effects, and other reasons. At this time, the emergence of immunotherapy represented by immune checkpoint inhibitors (ICIs) well breaks this embarrassing situation, which mainly achieves the anti-tumor purpose by improving the tumor immune microenvironment. Currently, ICI monotherapy, as well as combination therapy, has been widely used in the clinic, further prolonging the survival of patients with advanced hepatocellular carcinoma. This article reviews the development of monotherapy and combination therapy for ICIs in advanced hepatocellular carcinoma and the latest research progress.

Developing targeted therapeutics for hepatocellular carcinoma: a critical assessment of promising phase II agents

INTRODUCTION

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and the first for primary liver tumors. In recent years greater therapeutic advancement was represented by employment of tyrosine kinase inhibitors (TKIs) either in monotherapy or in combination with immune checkpoint inhibitors (ICIs).

AREAS COVERED

Major attention was given to target therapies in the last couple of years, especially in those currently under phase II trials. Priority was given either to combinations of novel ICI and TKIs or those targeting alternative mutations of major carcinogenic pathways.

EXPERT OPINION

As TKIs are playing a more crucial role in HCC therapeutic strategies, it is fundamental to further expand molecular testing and monitoring of acquired resistances. Despite the recent advancement in both laboratory and clinical studies, further research is necessary to face the discrepancy in clinical practice.

Chemotherapy-induced acetylation of ACLY by NAT10 promotes its nuclear accumulation and acetyl-CoA production to drive chemoresistance in hepatocellular carcinoma

Chemotherapeutic efficacy is seriously impeded by chemoresistance in more than half of hepatocellular carcinoma (HCC) patients. However, the mechanisms involved in chemotherapy-induced upregulation of chemoresistant genes are not fully understood. Here, this study unravels a novel mechanism controlling nuclear acetyl-CoA production to activate the transcription of chemoresistant genes in HCC. NAT10 is upregulated in HCC tissues and its upregulation is correlated with poor prognosis of HCC patients. NAT10 is also upregulated in chemoresistant HCC cells. Targeting NAT10 increases the cytotoxicity of chemotherapy in HCC cells and mouse xenografts. Upon chemotherapy, NAT10 translocates from the nucleolus to the nucleus to activate the transcription of CYP2C9 and PIK3R1. Additionally, nuclear acetyl-CoA is specifically upregulated by NAT10. Mechanistically, NAT10 binds with ACLY in the nucleus and acetylates ACLY at K468 to counteract the SQSTM1-mediated degradation upon chemotherapy. ACLY K468-Ac specifically accumulates in the nucleus and increases nuclear acetyl-CoA production to activate the transcription of CYP2C9 and PIK3R1 through enhancing H3K27ac. Importantly, K468 is required for nuclear localization of ACLY. Significantly, ACLY K468-Ac is upregulated in HCC tissues, and ablation of ACLY K468-Ac sensitizes HCC cells and mouse xenografts to chemotherapy. Collectively, these findings identify NAT10 as a novel chemoresistant driver and the blockage of NAT10-mediated ACLY K468-Ac possesses the potential to attenuate HCC chemoresistance.

Surgical resection versus thermal ablation after intra-arterial conversion therapy for unresectable hepatocellular carcinoma: a multicenter retrospective one as per the STROBE guidelines

PURPOSE

Intra-arterial conversion therapy (ICT) is a promising option for patients with unresectable hepatocellular carcinoma (uHCC). However, the selection of sequential therapeutic modalities is still controversial. This study compared the efficacy and safety of surgical resection (SR) versus thermal ablation (TA) after patients with uHCC received ICT.

METHODS

From May 2008 to November 2021, 3553 consecutive patients were reviewed and 791 patients were downstaged to receive TA or SR. Among them, 340 patients received SR, and 451 received TA after ICTs. The propensity score matching (PSM) method was applied to reduce selection bias between groups. Cumulative overall survival (OS) and progression-free survival (PFS) were compared using the Kaplan-Meier method with the log-rank test. The occurrence of complications and adverse events (AEs) were compared using chi-square test.

RESULTS

After PSM 1:1 (n = 185 in both groups), the 10-year OS and PFS rates for patients who underwent SR were comparable to those of patients who underwent TA (OS: 45.2% vs. 36.1%; p = 0.190; PFS: 19.3% vs. 15.9%; p = 0.533). A total of 237 (29.9%) patients (203 males; mean age:57.1 ± 11.0 years) received downstaging therapy, and long-term OS and PFS remained comparable between the two groups (p = 0.718, 0.636, respectively). However, the cumulative OS and PFS rates in the downstaged cohort were significantly higher than those in the nondownstaged cohort (both ps < 0.001). Additionally, there was no difference in major complications between the two groups (SR: 6.3% vs. TA: 8.6%; p = 0.320).

CONCLUSIONS

TA might be an acceptable first-line alternative to SR after patients with uHCC receive ICT, especially patients unsuitable for SR. Better long-term survival was observed among patients in the downstaged cohort compared to those who failed to downstage.

Pretreatment CT-based machine learning radiomics model predicts response in unresectable hepatocellular carcinoma treated with lenvatinib plus PD-1 inhibitors and interventional therapy

BACKGROUND

Lenvatinib plus PD-1 inhibitors and interventional (LPI) therapy have demonstrated promising treatment effects in unresectable hepatocellular carcinoma (HCC). However, biomarkers for predicting the response to LPI therapy remain to be further explored. We aimed to develop a radiomics model to noninvasively predict the efficacy of LPI therapy.

METHODS

Clinical data of patients with HCC receiving LPI therapy were collected in our institution. The clinical model was built with clinical information. Nine machine learning classifiers were tested and the multilayer perceptron classifier with optimal performance was used as the radiomics model. The clinical-radiomics model was constructed by integrating clinical and radiomics scores through logistic regression analysis.

RESULTS

151 patients were enrolled in this study (2:1 randomization, 101 and 50 in the training and validation cohorts), of which three achieved complete response, 69 showed partial response, 46 showed stable disease, and 33 showed progressive disease. The objective response rate, disease control rate, and conversion resection rates were 47.7, 78.1 and 23.2%. 14 features were selected from the initially extracted 1223 for radiomics model construction. The area under the curves of the radiomics model (0.900 for training and 0.893 for validation) were comparable to that of the clinical-radiomics model (0.912 for training and 0.892 for validation), and both were superior to the clinical model (0.669 for training and 0.585 for validation). Meanwhile, the radiomics model can categorize participants into high-risk and low-risk groups for progression-free survival (PFS) and overall survival (OS) in the training (HR 1.913, 95% CI 1.121 to 3.265, p=0.016 for PFS; HR 4.252, 95% CI 2.051 to 8.816, p=0.001 for OS) and validation sets (HR 2.347, 95% CI 1.095 to 5.031, p=0.012 for PFS; HR 2.592, 95% CI 1.050 to 6.394, p=0.019 for OS).

CONCLUSION

The promising machine learning radiomics model was developed and validated to predict the efficacy of LPI therapy for patients with HCC and perform risk stratification, with comparable performance to clinical-radiomics model.